Ethnicity
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OBJECTIVE: To determine whether an established patient satisfaction scale commonly used in the primary care setting is sufficiently sensitive to identify racial/ethnic differences in satisfaction that may exist; to compare a composite indicator of overall patient satisfaction with a 4-item satisfaction scale that measures only the quality of the direct physician-patient interaction.

DESIGN: Real-time survey of patients during a primary care office visit.

SETTING: Private medical offices in a generally affluent area of northern California.

PARTICIPANTS: Five hundred thirty-seven primary care patients selected at random from those entering a medical office.

MAIN OUTCOME MEASURES: Patient satisfaction using 1) a composite, 9-item satisfaction scale (VSQ-9); and 2) a 4-item subset of that scale that measures only satisfaction with direct physician care.

RESULTS: The 9-item, composite scale identified no significant difference in patient satisfaction between white and nonwhite patients, after controlling for patient demographics and other aspects of the visit. The 4-item, physician-specific scale indicated that nonwhite patients were less satisfied than white patients with their direct interaction with the physicians included in the study (P .01).

CONCLUSIONS: Measurements of patient satisfaction that use multi-item, composite indicators should also include focused comparisons of satisfaction directly with the care provided by the physician. In measurements of patient satisfaction, patient race/ethnicity should be included as an explanatory variable. The results also confirm earlier findings that factors external to the direct physician-patient interaction can have substantial effects on patients' perceptions of that interaction.

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Journal of General Internal Medicine
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Richard E. Behrman Professor of Child Health and Society
Senior Fellow, Freeman Spogli Institute for International Studies
rsd15_081_0253a.jpg MD, MPH

Dr. Paul Wise is dedicated to bridging the fields of child health equity, public policy, and international security studies. He is the Richard E. Behrman Professor of Child Health and Society and Professor of Pediatrics, Division of Neonatology and Developmental Medicine, and Health Policy at Stanford University. He is also co-Director, Stanford Center for Prematurity Research and a Senior Fellow in the Center on Democracy, Development, and the Rule of Law, and the Center for International Security and Cooperation, Freeman Spogli Institute for International Studies, Stanford University. Wise is a fellow of the American Academy of Arts and Sciences and has been working as the Juvenile Care Monitor for the U.S. Federal Court overseeing the treatment of migrant children in U.S. border detention facilities.

Wise received his A.B. degree summa cum laude in Latin American Studies and his M.D. degree from Cornell University, a Master of Public Health degree from the Harvard School of Public Health and did his pediatric training at the Children’s Hospital in Boston. His former positions include Director of Emergency and Primary Care Services at Boston Children’s Hospital, Director of the Harvard Institute for Reproductive and Child Health, Vice-Chief of the Division of Social Medicine and Health Inequalities at the Brigham and Women’s Hospital and Harvard Medical School and was the founding Director or the Center for Policy, Outcomes and Prevention, Stanford University School of Medicine. He has served in a variety of professional and consultative roles, including Special Assistant to the U.S. Surgeon General, Chair of the Steering Committee of the NIH Global Network for Women’s and Children’s Health Research, Chair of the Strategic Planning Task Force of the Secretary’s Committee on Genetics, Health and Society, a member of the Advisory Council of the National Institute of Child Health and Human Development, NIH, and the Health and Human Secretary’s Advisory Committee on Infant and Maternal Mortality.

Wise’s most recent U.S.-focused work has addressed disparities in birth outcomes, regionalized specialty care for children, and Medicaid. His international work has focused on women’s and child health in violent and politically complex environments, including Ukraine, Gaza, Central America, Venezuela, and children in detention on the U.S.-Mexico border.  

Core Faculty, Center on Democracy, Development and the Rule of Law
Affiliated faculty at the Center for International Security and Cooperation
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Donald K. Emmerson
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TERNATE, North Maluku, Indonesia: Indonesia's first direct presidential election was held peacefully last Monday. That fact alone spelled success in a troubled country with an authoritarian past. As vote totals mounted at election headquarters in Jakarta, observers could project not only the outcome--they could also look forward with some confidence to a democratic future for the fourth most populous country and largest Muslim society on earth.

Seen from below, however, the world's biggest and most complex democratic experiment amounts to a set of promises still waiting to be fulfilled.

Half an hour by speedboat from Ternate and two more hours by jeep on damaged roads across the remote island of Halmera lie two adjacent villages, Sosol and Tahane. A clash between them on the night of August 18, 1999 had triggered near-anarchy here in the northern Maluku archipelago. Muslims fought Christians, then Muslims fought Muslims. More than a thousand died.

An Indonesian colleague and I went there on election day. We wanted to know whether the balloting would help heal or reopen North Maluku's wounds.

Sosol is a Christian village. In a near-whisper that reflected the sensitivity of the topic, the village secretary blamed the 1999 outbreak squarely on Muslim militants in Tahane. They had attacked Sosol en masse, he said. They had thrown rocks and torched homes while screaming "Allahu Akbar"--"God is great." Christian villages had counterattacked.

Interviewed in his home just down the road, the village chief of all-Muslim Tahane remembered differently: "They acted first," he said. People in Sosol had been drinking alcohol, forbidden to Muslims. From his side of the border he could hear the shouts of drunken Sosolans abusing Tahane; the Sosolans began seizing Tahanean houses, slashing the furniture, he said. He admitted that the first to die was killed by a Tahanean, "but they started it," he insisted. "They had weapons - arrows, bombs. What was I to do? Let them roll over us?"

Ever since the chief and his fellow villagers had arrived in Tahane in the 1970s, evacuees from a feared volcanic eruption on their home island in the south, the Sosolans had hated them and tried to get them to leave. Or so he said.

The roots of this conflict embrace many issues. They include religion, migration, ethnicity, customs, and access to land. But it was an action taken by the central government in far-off Jakarta that lit this volatile mix in 1999--a decree that transferred Sosol and several other largely Christian villages to the jurisdication of a new and mostly Muslim subdistrict, including Tahane. What looked in Jakarta like a purely administrative arrangement appeared to Sosolans to threaten their identity.

It has never been realistic here to expect the national government to understand what goes on in and between particular villages--not in a country this vast, diverse, and underdeveloped.

But democracy raises expectations. What happened on July 5 linked the electorate directly, almost personally, to individual candidates running for president and vice-president of the entire country.

Throughout our election-date tour of polling stations in northern Maluku we came across evidence of disappointment and hope in roughly equal measure.

Every villager we met either was or had been a refugee from the violence of the 1990s, and nearly every one had suffered. Yet when we asked who had supplied them with emergency food and housing materials to survive the crisis and rebuild, our informants rarely mentioned the Indonesian government.

We also found good news. Although Sosol and Tahane voted for opposing slates, old wounds stayed closed. The villagers were not about to let political rivalries between presidential candidates rekindle calamity. There was no violence on voting day, and turnouts were high in all the villages. If democracy requires civility and participation, the people of northern Maluku are ready and willing to do their part.

But will Indonesia's new president, when finally elected in a run-off this September, be willing and able to his or her part? Will campaign promises be kept?

Perhaps the most poignant hint of this country's fragility occurred when I asked the Sosol village secretary, "What is Indonesia?" For the first time in our conversation, he fell silent. Try as he might, he could not answer.

At the risk of wishful thinking, one can hope the election itself was a kind of answer.

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Income, education, occupation, age, sex, marital status, and ethnicity are all correlated with health in one context or another. This paper reflects on the difficulties encountered in deriving robust scientific conclusions from these correlations or drawing reliable policy applications. Interactions among the variables, nonlinearities, casual inference, and possible mechanisms of action are discussed. Strategies for future work are suggested, and researchers are urged to pay special attention to possible interactions among health, genes, and socio-economic variables.

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Journal of Health Economics
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Singapore has become widely known as a successful experiment in multiracialism and meritocracy. The apparently successful management of ethnic relations in Singapore has been attributed to the ostensibly race-blind vision of its leaders. In his talk, Eugene Tan will challenge this orthodox interpretation. He will argue instead that Singapore's rulers have not only been acutely aware of ethnicity and its importance. They have intentionally mobilized race, culture, and language as key political resources to ensure that Singapore remains a sophisticated, authoritarian, developmental state.

Eugene Tan has been researching multiracialism in Singapore at Stanford on a Fulbright fellowship while on study leave from the Singapore Management University, where he is a lecturer in law.

This seminar is co-hosted by the Southeast Asia Forum at Shorenstein APARC and the Stanford Program in International Legal Studies, Stanford Law School. This is the eleventh SEAF seminar of the 2003-2004 academic year.

Daniel and Nancy Okimoto Conference Room

Eugene K.B. Tan Fellow Stanford Program in International Legal Studies, Stanford Law School
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616 Serra Street
Encina Hall, E106
Stanford, CA 94305-6055

(650) 723-0145 (650) 723-4811
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Visiting Scholar

Ludger Kuehnhardt was born in Muenster (Germany) in 1958. He is Director of the Center for European Integration Studies (ZEI), a think-tank of the University of Bonn which he helped to set up since 1997(www.zei.de). Prior to this, he was Chair of Political Science at the University of Freiburg and worked as Speechwriter for the former German President Richard von Weizsaecker. Ludger Kuehnhardt has been a Visiting Fellow ot Stanford's Hoover Institution in 1995/96. He was a Public-Policy Fellow at the Woodrow Wilson Center for International Scholars in Washington D.C. in 2002 and a Visiting Professor at Dartmouth College in 2000. He is a Visiting Professor at the Catholic University of Milan and at the Diplomatic Academy in Vienna.

Prof. Kuehnhardts research interests center on transatlantic relations and European foreign and security policy in light of the joint new challenges in the Greater Middle East. He is also conducting research on the constitution-building process of the European Union and its ramification for European identity. His research interests include the "globalization" of regional integration processes and its link to the European integration experience.

He has wide range experiences in political and academic consulting work and has lectured in all continents. He studied history, philosophy and political science in Bonn, Geneva, Tokyo and at Harvard's Center for European Studies.

Ludger Kuehnhardt is the author of more than twenty books on Europe, transatlantic relations,political theory and history of ideas.

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The goal of this study was to estimate the incidence of Parkinson's disease by age, gender, and ethnicity. Newly diagnosed Parkinson's disease cases in 1994-1995 were identified among members of the Kaiser Permanente Medical Care Program of Northern California, a large health maintenance organization. Each case met modified standardized criteria/Hughes diagnostic criteria as applied by a movement disorder specialist. Incidence rates per 100,000 person-years were calculated using the Kaiser Permanente membership information as the denominator and adjusted for age and/or gender using the direct method of standardization. A total of 588 newly diagnosed (incident) cases of Parkinson's disease were identified, which gave an overall annualized age- and gender-adjusted incidence rate of 13.4 per 100,000 (95% confidence interval (CI): 11.4, 15.5). The incidence rapidly increased over the age of 60 years, with only 4% of the cases being under the age of 50 years. The rate for men (19.0 per 100,000, 95% CI: 16.1, 21.8) was 91% higher than that for women (9.9 per 100,000, 95% CI: 7.6, 12.2). The age- and gender-adjusted rate per 100,000 was highest among Hispanics (16.6, 95% CI: 12.0, 21.3), followed by non-Hispanic Whites (13.6, 95% CI: 11.5, 15.7), Asians (11.3, 95% CI: 7.2, 15.3), and Blacks (10.2, 95% CI: 6.4, 14.0). These data suggest that the incidence of Parkinson's disease varies by race/ethnicity.

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Am J Epidemiol
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Lorene Nelson
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Patients requiring bilateral total knee arthroplasties may have both joints replaced simultaneously during one hospitalization (one-stage) or during two separate hospitalizations (two-stage). The goals of the current study were to retrospectively analyze discharge patterns for 91 patients who had one-stage bilateral total knee arthroplasties and 32 patients who had two-stage surgeries, and to quantify their in-hospital costs and their costs if the patients were discharged from the hospital to an inpatient unit. Patients having one-stage and two-stage surgery were similar in age, gender, severity of illness (as measured by the American Society of Anesthesiologists Physical Status score), principal diagnosis, and ethnicity. Using a microcosting approach, the authors found that the average in-hospital costs for one-stage total knee arthroplasty (27,468 US dollars) were significantly lower (by 24%) than for two-stage total knee arthroplasty. However, 38% of patients who had the one-stage bilateral total knee arthroplasties were admitted to an acute rehabilitation unit, which had a mean cost of 6469 US dollars and length of stay of 9 days. In contrast, none of the patients who had the two-stage procedure required acute rehabilitation. Patients who had the two-stage procedure were discharged directly home (or with home health services) 42% of the time, versus 21% for patients who had the one-stage procedure. Patients from both groups were discharged to a skilled nursing facility approximately (1/2) of the time, accruing similar costs. Economic analyses of the one-stage procedure need to consider that these patients will require increased use of acute inpatient rehabilitation after hospital discharge.

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Clinical Orthopedics and Related Research
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Alex Macario
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In this unit the geographic distribution of China's ethnic groups will be introduced, as well as the cultural and linguistic features of China's major ethnic groups. Focusing on the Hui, Tibetans, Mongols, and the Miao, topics such as ethnogenesis, sovereignty, assimilation, and stereotypes and representation are addressed.

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